AHA/ACSM Health/Fitness Facility Preparticipation Screening Questionnaire

Assess your health needs by marking all true statements.

History
You have had: If you marked any of the statements in this section,
consult your physician or other appropriate healthcare
___ A heart attack
provider before engaging in exercise. You may need
___ Heart surgery to use a facility with a medically qualified staff.
___ Cardiac catheterization
___ Coronary angioplasty (PTCA)
___ Pacemaker/implantable cardiac defibrillator/rhythm disturbance
___ Heart valve disease Other health issues
___ Heart failure ___ You have diabetes
___ Heart transplantation ___ You have or asthma other lung disease.
___ Congenital heart disease ___ You have burning or cramping in your lower legs
when walking short distances.
Symptoms ___ You have musculoskeletal problems that limit your
___ You experience chest discomfort with exertion. physical activity.
___ You experience unreasonable breathlessness. ___ You have concerns about the safety of exercise.
___ You experience dizziness, fainting, blackouts. ___ You take prescription medication(s).
___ You take heart medications. ___ You are pregnant.
_________________________________________ ____________________________________________

Cardiovascular risk factors

___ You are a man older than 45 years.
___ You are a woman older than 55 years, you
have had a hysterectomy, or you are postmenopausal.
___ You smoke, or quite within the previous 6 mo.

If you marked two or more of the statements in this

___ Your BP is greater than 140/90.

section, you should consult your physician or other

___ You don't know your BP.
appropriate healthcare provider before engaging in
___ You take BP medication.
exercise. You might benefit by using a facility with a
___ Your blood cholesterol level is >200 mg/dL.
professionally qualified exercise staff to guide
your exercise program.
___ You don't know your cholesterol level.

___ You have a close blood relative who had a heart attack before age 55 (father or brother) or age 65 (mother or

sister).

___ You are physically inactive (i.e., you get less than 30 min. of physical activity on at least 3 days per week).

___ You are more than 20 pounds overweight.

_________________________________________ ____________________________________________

___ None of the above is true. You should be able to exercise safely without consulting
your physician or other healthcare provider in a self-
guided program or almost any facility that meets your
exercise program needs.
_________________________________________ ____________________________________________
Balady et al. (1998). AHA/ACSM Joint Statement: Recommendations for Cardiovascular Screening, Staffing, and Emergency Policies at Health/Fitness
th
Facilities. Medicine & Science in Sports & Exercise, 30(6). (Also in: ACSM’s Guidelines for Exercise Testing and Prescription, 7 Edition, 2005.
Lippincott Williams and Wilkins http://www.lww.com )

www.acsm-msse.org/pt/pt-core/template-journal/msse/media/0698c.htm